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We consider applications for all positions without regard to race, color, religion, creed,
gender; national origin, age, disability, marital or veteran status, or any other legally
protected status.
(PLEASE PRINT)
APPLICATION
FOR EMPLOYMENT
Advertisement Relative Inquiry
Employment Agency Friend Other _______________________________________
Position(s) Applied for Date of Application
How Did You Learn About Us?
Last Name First Name Middle Name
Address Number Street City State Zip Code
Telephone Number(s) Social Security Number
County of Northumberland Department of Human Resources
399 S. Fifth Street
Sunbury, Pa 17801
Best time to contact you at home is: .......................................................................................................... ____ : _________
If you are under 18 years of age, can you provide required
Proof of your eligibility to work?............................................................................................................... Yes No
Have you ever filed an application with us before? ................................................................................... Yes No
If Yes, give date ____________________
Have you ever been employed with us before?.......................................................................................... Yes No
If Yes, give date ____________________
Do any of your friends or relatives, other than spouse, work here? ........................................................... Yes No
Are you currently employed?..................................................................................................................... Yes No
May we contact your present employer?.................................................................................................... Yes No
Are you prevented from lawfully becoming employed in this
Country because of Visa or Immigration Status?....................................................................................... Yes No
Proof of citizenship or immigration status will be required upon employment
Date available for work ____/____/____ What is your desired salary range? _______________
Are you available to work: Full-Time (please indicate 1 2 3 shift)
Part-Time (please indicate Morning Afternoon Evenings)
Temporary (please indicate dates available ___/___/___ - ___/___/___)
Are you currently on “lay-off” status and subject to recall? ...................................................................... Yes No
Can you travel if a job requires it? ............................................................................................................. Yes No
Have you been convicted of a felony within the last five years? ............................................................... Yes No A criminal record does not constitute an automatic bar to employment and will be considered only as it relates to the job in question.
AM
PM
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
EDUCATION
Name and Address
of School Course of Study
Years
Completed
Diploma
Degree
Elementary
School
High
School
Undergraduate
College
Graduate
Professional
Other
(Specify)
Describe any specialized training, apprenticeship, skills and extra-curricular activities.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Describe any job-related training received in the United States military.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Employer Dates Employed Work Performed
From To
Address
Telephone Number(s)
Job Title Supervisor Starting Final
Reason for Leaving
Hourly Rate/Salary
EMPLOYMENT EXPERIENCE Start with your present or last job. Include any job-related military service assignments and volunteer ac-
tivities. You may exclude organizations which indicate race, color, religion, gender; nation origin, disabili-
ties or other protected status.
Employer Dates Employed Work Performed
From To
Address
Telephone Number(s)
Job Title Supervisor Starting Final
Reason for Leaving
Hourly Rate/Salary
Employer Dates Employed Work Performed
From To
Address
Telephone Number(s)
Job Title Supervisor Starting Final
Reason for Leaving
Hourly Rate/Salary
Employer Dates Employed Work Performed
From To
Address
Telephone Number(s)
Job Title Supervisor Starting Final
Reason for Leaving
Hourly Rate/Salary
If you need additional space, please continue on a separate sheet of paper.
List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal gender, race, national origin, age, ancestry, disability or other
protected status:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
1
2
3
4
ADDITIONAL INFORMATION
Other Qualifications Summarize special job-related skills and qualifications acquired from employment or other experience.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
SPECIAL SKILLS (CHECK SKILLS/EQUIPMENT OPERATED)
____ Terminal
____ PC/MAC
____ Typewriter
WPM ____
____ Spreadsheet
____ Word Processing
____ Shorthand
WPM ____
Production/Mobile
Machinery (list)
______________________
______________________
______________________
______________________
Other (list)
______________________
______________________
______________________
______________________
State any additional information you feel may be helpful to us in considering
your application
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN
INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.
Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the
actives involved in the job or occupation for which you have applied? A review of the activities involved
in such a job or occupation has been given. ___ YES ___ NO
REFERENCES
1 ( ) (Name) Phone #
(Address)
2 ( ) (Name) Phone #
(Address)
3 ( ) (Name) Phone #
(Address)
APPLICANT’S STATEMENT
I certify that answers given herein are true and complete.
I authorize investigation of all statements contained in this application for employment as may be neces-
sary in arriving at an employment decision.
This application for employment shall be considered active for a period of time not to exceed 45 days.
Any applicant wishing to be considered for employment beyond this time period should inquire as to
whether or not applications are being accepted at that time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment
relationship with this organization is of an “at will” nature, which means that the Employee may resign at
any time and the Employer may discharge Employee at any time with or without cause. It is further under-
stood that this “at will” employment relationship may not be changed by any written document or by con-
duct unless such change is specifically acknowledged in writing by an authorized executive of this organi-
zation.
In the event of employment, I understand that false or misleading information given in my application or
interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regula-
tions of the employer:
________________________________________ _______________________
Signature of Applicant Date
Arrange Interview Yes No
Remarks _________________________________________________________________________
_____________________________________________ _________________________ INTERVIEWER DATE Employed Yes No Date of Employment ________________________________
Hourly Rate/
Job Title __________________ Salary ________________ Department ______________________
By _________________________________________________________________ NAME AND TITLE DATE
FOR PERSONNEL DEPARTMENT USE ONLY
This Application For Employment is sold for general use throughout the United States. Amsterdam Printing and Litho assumes
no responsibility for the use of said form or questions which, when asked by the employer of the job applicant, may violate State
and/or Federal Law.
Employment Application Supplement
County of Northumberland Department of Human Resources
399 S. 5th Street Sunbury, PA 17801
Yes No
HAVE YOU EVER BEEN CONVICTED OF A CRIME, including a moving traffic violation, summary, misdemeanor and felonies? If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. Note: A Yes response does not automatically disqualify your application. If yes Please Explain: (attach additional sheets as necessary)
Yes No
Are you currently out on bail or release on your own recognizance pending trial? If yes, please explain.
The above information is true and correct. I understand that the hiring process will be terminated, or in the event of my
employment by the County, I shall be subjected to dismissal, if any information that I have given in this application, the
background release form, in any resume or interview or any part of the hiring process is false or misleading or if I have failed to
give any information herein requested, or if I have withheld relevant information, regardless of the time elapsed after discovery.
I authorize the County to inquire into my education, professional and past employment history references as needed to research
my qualifications for this position. I hereby give my consent to any former employer to provide employment-related informa-
tion about me to the County and will hold the County any my former employer harmless from any claim made on the basis that
such information about me was provided or that any employment decision was made on the basis of such information. I
understand that the Cou8nty will provide a separate Disclosure and Release required by law that will permit the County to make
such inquires through the services of a third party.
If employed, I will be required to provide original documents which verify my identity and right to work in the United States
under the Immigration Reform and Control Act (IRCA) of 1986. The document(s) provided will be used for completion of
Form I-9.
________________________________________________________
Signature Date
NORTHUMBERLAND COUNTY
AUTHORIZATION TO OBTAIN INFORMATION/WAIVER
I, _________________________________________, having made application for
employment with Northumberland County, understand that Northumberland County desires to
obtain information concerning my background and character in order to better ascertain my
qualifications for employment.
I hereby authorize Northumberland County to investigate and ascertain any and all
information concerning my background and character, which may be pertinent to my
application for employment with Northumberland County. I understand that the information
may be obtained from any person, document or other source, within or outside the
Commonwealth of Pennsylvania.
I hereby release all persons and Northumberland County from any liability, which might
otherwise result from the release of, said information to any member of Northumberland
County.
In consideration of this release, Northumberland County shall regard all information
obtained as confidential. I understand that the same shall not be released to any individual,
including organization, absent good cause or myself.
I agree that Northumberland County may admit this information into evidence in order
to defend any administrative or court proceeding, which is initiated on my behalf. I regain the
right to challenge the accuracy of such information, in such a proceeding, but waive all
objections as to the admissibility of the information.
I understand that I am not compelled to sign this authorization.
_______________________________________________ _______________________ Applicant’s Signature Date
_________________________________________ _________________________________________________
Social Security Witness Signature
I, ___________________________________________, having made application for employment with
Northumberland County, do not desire to sign the authorization stated above. I understand that if
Northumberland County is unable, through the exercise of reasonably diligent investigative methods, to
obtain information concerning my background and character which is necessary to evaluate my
qualification to be accepted fro employment by Northumberland County, I may be passed over for such
employment.
___________________________________________ __________________________________________
Applicant’s Signature Witness Signature
___________________________________________
Date